Managing Cardiac & Pulmonary Risk in the Surgical Patient

Managing Cardiac & Pulmonary Risk in the Surgical Patient Hugo Quinny Cheng, MD Division of Hospital Medicine University of California, San Francisco Preoperative Evaluation Guidelines Cardiac: Fleisher L et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery (2014). J Am Coll Cardiol. doi: 10.1016/j.jacc.2014.07.944. Pulmonary: Qaseem A et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med, 2006; 141:575-80. 1

Preoperative Cardiac Evaluation Is this patient at increased risk for perioperative cardiac complications? Does the patient need further preoperative medical tests to clarify this risk? What should be done to reduce the risk of cardiac complications? Clinical Risk Prediction 70-y.o. man with progressive weakness due to cervical myelopathy need spinal decompression & fusion. He needs help with some ADLs and walks slowly with a cane. He has stable coronary artery disease & HTN He is an active smoker. What increases this patient s risk for perioperative cardiac complications? 2

Question 1: What increases this patient s risk for perioperative cardiac complications? 1. History of coronary disease 2. History of HTN 3. Current tobacco use 4. Limited functional status 5. All of the above Identifying Higher Risk Patients Known cardiovascular disease predicts risk Atherogenic risk factors (except diabetes) do not Risk Factor Odds Ratio Ischemic heart disease 2.4 Congestive heart failure 1.9 Diabetes 2.8 History of Stroke or TIA 3.2 Poor functional status 1.8 3

Surgery Specific Risk High Major aortic or peripheral vascular surgery (> 5 % risk) Emergent major surgery Long cases w/ large fluid shifts or blood loss Intermediate Carotid endarterectomy (< 5 % risk) Head & Neck Abdominal & Thoracic Orthopedic Low Endoscopic procedures (< 1% risk) Skin & Breast Revised Cardiac Risk Index Predictors: Ischemic heart disease Congestive heart failure Diabetes requiring insulin Creatinine > 2 mg/dl Stroke or TIA High Risk operation (intraperitoneal, intrathoracic, or suprainguinal vascular) # of RCRI Complications Predictors MI & cardiac arrest 0 0.4% 1 1% 2 2.4% 3 5.4% RCRI > 2 is Elevated Risk Devereaux PJ et al. CMAJ 2005; 173:627. 4

New Cardiac Risk Prediction Tool Derived from National Surgical Quality Improvement Program (NSQIP) database: > 400,000 patients in derivation & validation cohorts Wide range of operations Complication = 30-day incidence of MI & cardiac arrest Independent Predictors 1. Type of surgery 2. Age 3. Serum creatinine > 1.5 mg/dl 4. Functional status (dependency for ADLs) 5. American Society of Anesth (ASA) class Gupta PK et al. Circulation 2011; 124:681 ASA Class (a brief digression) American Society of Anesthesiologists Physical Classification 1. Healthy, normal 2. Mild systemic disease 3. Severe systemic disease 4. Severe systemic disease that is a constant threat to life 5. Moribund patient not expected to survive without surgery 5

NSQIP Cardiac Risk Calculator 70-y.o. with h/o CAD, now undergoing cervical spine surgery. Needs help with some ADLs. Age 70 Cr < 1.5 ASA Class 3 Partially dependent Spine surgery www.qxmd.com/calculate-online/cardiology/gupta-perioperativecardiac-risk www.qxmd.com/calculate-online/cardiology/gupta-perioperativecardiac-risk 6

70-y.o. with h/o CAD, stroke, IDDM undergoing cervical spine surgery for progressive weakness. 0.72% www.qxmd.com/calculate-online/cardiology/gupta-perioperative-cardiac-risk Other findings: Excellent performance (AUC = 0.88) Caveats: Didn t look at all possible variables (e.g., TTE, stress test) Which Prediction Tool is Better? RCRI NSQIP Sample size ~4000 ~400,000 # of hospitals 1 > 200 Currency of data 89 94 07 08 Screen for MI? CK-MB, ECG No Which to choose? 2014 ACC/AHA guideline endorses both tools Personal practice: use NSQIP when quantifying risk 7

ACC/AHA: When is Risk Excessive? Unstable coronary syndromes Recent MI with post-infarct ischemia Class III or IV angina Decompensated CHF Significant arrhythmia High grade atrioventricular block Symptomatic ventricular arrhythmia Supraventricular arrhythmia with uncontrolled rate Severe valve disease (e.g., critical aortic stenosis) ACC/AHA: When is Risk Excessive? Severe or unstable cardiac disease that requires urgent evaluation & treatment, regardless of planned surgery 8

Utility of Stress Testing A 63 y.o. man will undergo a Whipple procedure for newly diagnosed pancreatic cancer. He had a remote myocardial infarction, diabetes, and HTN. He has not had chest pain in the past year. Meds: PEx: ECG: lovastatin, atenolol, glyburide, benazepril, ASA BP=115 / 70 HR=60; normal heart & lung exam NSR, LVH, otherwise normal Should this patient receive further preoperative tests? Question 2: 63 y.o. man s/f Whipple procedure. Remote MI, long-standing diabetes & HTN. No chest pain. Should this patient receive further preoperative tests? 1. No further testing 2. Yes, exercise ECG 3. Yes, nuclear scintigraphy 9

Noninvasive Stress Testing Predictive value: Mainly studied in vascular surgery patients Strong negative predictive value ~ 98% (neg LR = 0.1-0.2) Weak positive predictive value ~10-20% (pos LR = 2-3) Adds little information to lower risk patients More useful for cases with increased risk Stress Tests: More Useful in Patients at Higher Risk Pretest Probability = 1% (e.g. TKA) Positive Test: Posttest probability = 2-3% Negative Test: Posttest probability = 0-1% Pretest Probability = 10% (e.g. AAA repair) Positive Test: Posttest probability = 18-25% Negative Test: Posttest probability = 2% 10

2014 ACC/AHA Guideline Low Clinical Risk? (< 1% or RCRI = 0 or 1) yes Go to OR no Functional Capacity? >4 METs Go to OR 2a if > 10 METs 2b if 4-10 METs < 4 METs or? Will stress test result change management? no yes Go to OR or consider alternative approach Obtain pharmacologic stress test 2a Revascularization You diagnose a 63 y.o. man with resectable pancreatic cancer. He has known coronary disease. P-Mibi & angiography last year showed mild inferior reversibility and a 75% RCA lesion and normal LVEF. He did not receive PCI. Meds: PEx: lovastatin, atenolol, benazepril, ASA BP=115 / 70 HR=60; normal CV & lung exam Should this patient have coronary revascularization? 11

Question 3: 63 y.o. man with CAD undergoing Whipple procedure. His P-Mibi showed mild inferior reversibility. Angiogram showed a 75% RCA lesion and normal LVEF. 1. No, proceed to surgery 2. Consult cardiologist for possible PCI CARP Trial: Coronary Artery Revascularization Prophylaxis 510 patients undergoing vascular surgery At least 1 vessel with 70% occlusion Excluded left main dz, AS, or LVEF < 20% Choice of CABG or PCI plus Medical management Medical management alone McFalls, et al. NEJM, 2004 1 Endpoint: Long-term mortality 2 Endpoint: MI, Stroke, Limb loss, Dialysis 12

CARP: Complications After CABG or PCI Complication % Mortality 1.7% MI 5.8% Reoperation 2.5% McFalls EO, et al. N Engl J Med. 2004;351:2795-2804. CARP: Outcomes After Vascular Surgery Revascularized (n=225) Med Mgt Only (n=237) Death before surgery 10 (4%) 1 Death < 30 days post-op 7 (3%) 8 (3%) Postoperative MI 26 (12%) 34 (14%) Long-term mortality (2.7 yrs after randomization) 70 (22%) 67 (23%) p = NS for all comparisons McFalls EO, et al. N Engl J Med. 2004;351:2795-2804. 13

ACC/AHA Guidelines for PCI Indications for PCI are same as for nonsurgical patients Avoid PCI if antiplatelet drugs will need to be held prematurely Delay elective surgery after elective PCI: Bare metal stent: 30 days Drug eluting stent: 6 months (optimal) 3 months (if harm in delay) Continue or restart antiplatelet agents (especially ASA) as soon as possible, unless bleeding risk precludes Beta-blockers A 75 y.o. woman with diabetes and HTN will undergo revision of an infected knee arthoplasty. Denies cardiac history or symptoms. She is not on a beta-blocker. Her examination and ECG are unremarkable. Should this patient be started on a beta-blocker? 14

Question 4: 75 y.o. woman with stable coronary disease and HTN will undergo hip fracture repair. Not currently on -blocker. Should this patient be started on a beta-blocker now? 1. Oh yeah, definitely 2. Probably 3. Probably not 4. Are you crazy? No! POISE: Biggest β-blocker Trial Patients: 8351 pts with s/f major noncardiac surgery CAD, CHF, CVA/TIA, CKD, DM, or high-risk surgery Not already taking -blocker 2-4 h OR 0-6 h 12 h 1st dose Metoprolol XL 100 mg* 2nd dose Metoprolol XL 100 mg* 3rd & daily dose Metoprolol XL 200 mg*^ * Study drug held for SBP < 100 or HR < 50 ^ Daily dose reduced to 100 mg if persistent bradycardia or hypotension Outcome: 30-day cardiac mortality, nonfatal arrest or MI Poise Study Group. Lancet, 2008 15

POISE: Results 8% 7% 6% 5% 4% 3% 2% 1% 6.9% 5.8% Placebo Metoprolol XL 3.1% 2.3% Metoprolol XL: Reduced cardiac events (mostly nonfatal MI) but Increased risk of stroke & total mortality 0% CV Death, Cardiac Arrest, Nonfatal MI Total Mortality Poise Study Group. Lancet, 2008 2014 ACC / AHA Guideline for -blockers Definite indications to continue if (Helps) Already using -blocker to treat angina, HTN, arrhythmia Reasonable to consider initiation if (Maybe) High clinical risk (RCRI score > 3) Ischemia seen on preoperative stress test Compelling indication for long-term beta-blockade Avoid initiation On day of surgery (Harms) 16

Take Home Points Use a validated clinical prediction tool: RCRI is easy to use & has become the new standard NSQIP tool may be more broadly applicable Reserve stress testing for highest risk patients: Elevated risk and poor functional status Only do stress test if results will change management (e.g., cancel, delay, or modify surgery) Take Home Points Beware perioperative coronary revascularization: Indications are the same as for non-surgical patients Don t perform PCI if patient may have upcoming surgery that requires stopping antiplatelet therapy Beta-blockers: Only consider starting in very high risk patients after considering risks Start cautiously at least 1 day prior to surgery 17

Preoperative Pulmonary Evaluation Is this patient at increased risk for perioperative pulmonary complications? Does the patient need further preoperative medical tests to clarify this risk? What should be done to reduce the risk of pulmonary complications? 18

Pulmonary Risk Prediction A 65 y.o. man is to undergo repair of an abdominal aortic aneurysm. He has COPD and continues to smoke. He denies change in cough, or worsening of his chronic dyspnea when walking uphill. Exam: Resp Rate 20 O2 sat 95% RA Lungs: prolonged expiration, no wheeze What do you recommend for this patient? Question 5: 65 y.o. man is s/f repair of an AAA. He has COPD and smokes. No change in cough or usual chronic dyspnea. What do you recommend for this patient? 1. Obtain PFTs 2. Quit smoking first 3. Incentive spirometry after surgery 19

Pathophysiology of Postoperative Pulmonary Complications Normal Tidal Breathing Decreased FRC Incisional pain Anesthesia Supine position Abnormally high Closing Volume Closing Volume Age COPD Smoking Procedure Related Risk Factors Surgical Site Risk Factor Odds Ratio Neurosurgery 2.5 Head & Neck 2.2 Aortic 6.9 Thoracic 4.2 Abdominal 3.0 Vascular 2.1 Emergency surgery 2.2 Prolonged surgery 2.3 General anesthesia 1.8 20

Patient Related Risk Factors Risk Factor Odds Ratio Age 60-69 2.3 70-79 5.6 Congestive heart failure 2.9 COPD 2.4 ASA Class II vs. Class I Odds ratio = 4.9 ASA Class III vs. Class I or II Odds ratio = 3.1 Class I: no systemic disease Class II: mild systemic disease Class III: severe systemic disease Class IV: systemic disease that is a constant threat to life Respiratory Failure Prediction Tool Derived from National Surgical Quality Improvement Program (NSQIP) database: > 400 K patients in derivation & validation cohorts Wide range of operations Respiratory Failure = on vent > 48 hrs or reintubation Independent Predictors 1. American Society of Anesth (ASA) class 2. Functional status (dependency) 3. Type / location of surgery 4. Emergency surgery 5. Preoperative sepsis or SIRS Gupta PK et al. Chest 2011; 110:1207 21

Emergency surgery? No ASA Class 3 (severe systemic) Function/dependency Independent Surgery type Aortic Sepsis or SIRS? No www.qxmd.com/calculateonline/respirology/postoperative-respiratoryfailure-risk-calculator www.qxmd.com/calculateonline/respirology/postoperative-respiratoryfailure-risk-calculator Emergency surgery? No ASA Class 3 (severe systemic) Function/dependency Independent Estimated risk of postoperative respiratory failure: 6.7 % Surgery type Aortic Sepsis or SIRS? No 22

Pulmonary Function Tests & Spirometry PFTs & spirometry add little to risk assessment Usually just tells you what you already know Abnormal chest exam findings more predictive of PPC Can t use results to identify patients with prohibitively high risk of PPC or mortality Use as diagnostic tool to evaluate unexplained findings Maybe to assess whether COPD patients are at baseline (if clinical judgment equivocal) Preoperative Prevention Strategies Optimize chronic lung disease Treat COPD exacerbation (steroids, antbiotics) Smoking cessation Limited evidence for benefit for PPC but other benefits May require 8 weeks of cessation for benefit Respiratory conditioning Education on lung expansion & Inspiratory muscle training Benefit seen in RCTs in cardiac surgery Nutrition No benefit to hyperalimentation (enteral or TPN) 23

Preoperative Smoking Cessation Counseling RCTs of Preoperative Smoking Cessation Counseling: 1. 120 patients undergoing arthroplasty in 6-8 weeks 2. 60 patients undergoing colorectal resection in 2-3 weeks Intervention: Smoking cessation counseling & offer free nicotine replacement products Outcomes: Postop complications, especially wound related (e.g., dehiscence, infection, hematoma) Smoking Cessation 6-8 Weeks Before TKA or THA Moller et al. Lancet, 2002 24

Smoking Cessation 2-3 Weeks Before Colorectal Surgery Sorensen, et al. Colorectal Dis, 2003 Postoperative Prevention Strategies Lung expansion maneuvers Deep breathing or incentive spirometry recommended, though quality of evidence poor Consideration of CPAP for very high risk patients I COUGH a multi-intervention strategy to prevent PPC Incentive spirometry, Coughing & deep breathing, Oral care, Understanding, Get out of bed tid, Head of bed elevated Reduced postop pneumonia and unplanned reintubation Cassidy MR, et al. JAMA Surg. 2013 Aug;148(8):740-5 25

Causes of Postoperative Hypoxemia Upper airway obstruction Early onset - often POD 0 or prior to leaving PACU Airway edema, vocal cord injury, laryngospasm, OSA Atelectasis Often onset POD 1-2 Secretion management: chest therapy, pulmonary toilet Positive airway pressure: CPAP, BiPAP, EzPAP Pulmonary edema Often onset by POD 2 Cardiogenic vs. non-cardiogenic Causes of Postoperative Hypoxemia Pneumonia Most common in first 5 days postop (unless on ventilator) Think Staph aureus & gram negative rods Pseudomonas? Risk with 5 days hospitalization or prior antibiotic exposure, dialysis, nursing home Other etiologies: Pulmonary embolism Bronchospasm Effusions common after abdominal surgery, usually small, exudative and usually don t require treatment 26

Take Home Points Patient related risks: Elderly COPD Severe medical comorbidity Functionally dependent or generally debilitated Procedure related risks: Thoracic surgery Abdominal surgery Emergency surgery Prolonged surgery > 3 hrs General anesthesia Take Home Points Chest x-rays and PFTs: Should not be done routinely Consider spirometry to evaluate unexplained symptoms Risk Reduction: Patients at increased risk for pulmonary complications should receive lung expansion maneuvers Smoking cessation likely beneficial but may require two months lead time to be effective 27

Thank You quinny.cheng@ucsf.edu 28